Recently, the Department of Justice (“DOJ”) intervened in a qui tam whistleblower suit in the US District Court for the Southern District of new York, which involves Continuum Health Partners and several Mount Sinai-related hospitals. United States ex. Rel. Kane v. Continuum Health Partners, Inc. et al, (Civil Action, No. 11-2325(ER)). While DOJ intervention in whistleblower cases is not unusual, this case is significant because the DOJ’s complaint specifically alleges that the defendants failed to return Medicaid overpayments within 60 days, as required by the Affordable Care Act (“ACA”). The case is one of the first to explore the issues and interpret the requirements of the 60-Day Rule. More >

In Kentucky, most trade association-sponsored health plans renew on July 1, 2014. Now is an excellent time for trade association executives to review association and Health Plan materials to ensure compliance with applicable Federal and State requirements prior to renewal. More >

On February 4, McBrayer and Business Lexington presented a panel discussion on how small businesses can navigate the Affordable Care Act. I was honored to moderate the event and hope that attendees benefited from the panel’s real-world advice on how to traverse the new landscape of health insurance. A huge thank you to the panelists: Jon Carroll, Beverly Clemons, Betsy Johnson, Cris Miller, and Garry Ramsey. More >

Earlier this week, we discussed the benefits of all-payer claims database (“APCD”) systems. Nine states currently have APCDs in place, but Kentucky is not one of them. These systems provide a multitude of information on the cost, use, and quality of health care in a given state, but the question remains: how do providers feel about APCDs? More >

Over the last decade, many states have established all-payer claims database (“APCD”) systems that collect medical, pharmaceutical, and dental eligibility and claims information. Payers, including insurance providers, third-party administrators, prescription drug plans, Medicaid, and Medicare, are responsible for depositing eligibility and claims data into a collective system. The data can then be used to generate important information about cost and quality of care. By gathering detailed information in one place, a statewide picture emerges – information on service providers, patient demographics, and other important healthcare data. More >

In a 2009 speech to the American Medical Association, President Obama promised, “If you like your health-care plan, you’ll be able to keep your health-care plan, period. No one will take it away, no matter what.” This declaration came as the health care law was being written and similar statements were repeated by the President after the bill became law. More >

HealthCare.gov’s technical woes are expected to be fixed by November 30th. But, those fixes might come too late for a certain subset of needed enrollees – the young and healthy. The purpose behind the Affordable Care Act’s individual health insurance mandate was to ensure that private insurers would get enough young, healthy people in the system who could offset the costs of covering older and sicker, Medicaid-eligible patients. More >

Everyone, especially those in the health care industry, waited with bated breath to see the nationwide launch of the online health insurance marketplaces on October 1st. The launch was plagued with website malfunctions and connectivity problems in some states, including Kentucky, but programs across the country welcomed people clamoring for a look at America’s new health care options. Proponents of the exchanges say that the glitches and initial setbacks are a good sign – the overwhelming traffic to the websites show that people are actively seeking health care. Health reform opponents see the initial problems as a sign that the exchanges, and health reform generally, are too cumbersome and complicated to implement effectively. More >

On Tuesday, the Obama Administration announced that enforcement of the employer mandate provision of the Affordable Care Act (“ACA”) would be delayed until 2015, a year from its intended January 2014 start. The mandate requires that businesses with 50 or more full-time equivalent employees provide affordable health insurance for those employees or pay penalties. The administration has been under substantial pressure to delay the mandate, in large part because employers are still struggling with understanding and implementing the provisions. Some small businesses had even considered reducing their workforces below the 50-employee threshold or cutting employee hours to escape penalties for not providing coverage. More >

For over 200 years, professional courtesy has been a hallmark of physician practice, a symbol of collegiality among doctors. Historians describe its 18th century beginnings as physicians providing charity care for the families of their deceased colleagues—an early form of health insurance for doctors’ widows and children. Over the years, the concept of collegial care also became the preferred alternative to physicians treating themselves or their own family members. In fact, the American Medical Association’s (“AMA”) first code of medical ethics created an obligation among doctors to reciprocate medical care and to extend the courtesy to physician family members as well. Today, the AMA recognizes professional courtesy as a “long-standing tradition” but not an ethical requirement.[1] The federal government’s commentary about “the provision of free or discounted health care items or services to a physician or his or her immediate family members or office staff,” however, is far more cautious than nostalgic. [2] The Department of Health and Human Services Office of Inspector General’s advice that physicians “consult with an attorney” before extending professional courtesy warns that certain arrangements for free or discounted medical care run afoul of fraud and abuse laws.[3]More >